normofthenorth

Maybe healing a bit short is scary after all!

Written on April 30, 2012 – 9:22 pm | by normofthenorth

I saw a nifty podiatrist/chiropodist today, here in Toronto. (The two names are interchangeable here, though apparently not elsewhere.) My immediate problem was a nasty corn on top of a “hammertoe” that got very upset on my first ski week in Whistler, back in Jan-Feb. The bad toe was on my RIGHT foot, the one I’ve been calling my “good” one, though I did an ATR on that side in late 2001, and had it repaired surgically.

He examined my feet and legs and analyzed my gait very carefully, and told me I had CLAWtoes, not hammertoes. On both feet, too, though the causes were different. On the left, I’m compensating for a deficit in strength and stability, left over from my ATR. But it was my right ankle that worried him the most!

He says that I’ve been over-compensating for a deficit in dorsiflexion ROM, left over from my ATR surgery. When I mentioned it to my surgeon ~10 years ago, he said he did it on purpose, because “healing long” creates a functional deficit and healing short doesn’t. And I’ve basically agreed with him ever since. But no!!

This Doc said that my basic DF ROM was less than 15 degrees, which is the standard minimum a person needs to stride normally. (I.e., when you walk over your planted foot, that foot has to flex to 15 degs of DF to stay on the floor while your weight shifts to the other foot.) I don’t have that on my right (10 year post-op) ankle, so there are a few ways to “make do”:
(1) I could splay my toes out to the side. (I may do that when crouching on the volleyball court, but I don’t do that when walking.)
(2) I could hyper-extend my knee(s). (I did that as a kid, but he doesn’t think I’m doing it now while walking.)
(3) I could lift my heel earlier in my stride than “normal”. (I DO do that.) And
(4) I could open or dislocate the joint on the top of my foot, medial side, in front of my leg, which collapses my arch and gains me some DF ROM. (I DO do that, too.)

That joint involves the “halus” (bone? joint?), apparently. And he says that continuing to open or dislocate that joint while it’s got my FW (180-ish pounds) on it will eventually destroy the joint, and it will collapse.

He prescribed a few solutions:
(1) I can try some stretching, being careful to keep that joint closed while I’m doing it. One way is to push my thumb into the joint (where he did), but that’s hard while doing a WB stretch. The other is just to make sure that my knee and center-of-gravity are “inside”, almost in line with my big toe, when I stretch. He admitted that it was a long shot that stretching would gain me much AT-and-calf length 10 years after the surgery, but he thought it was worth trying for a few weeks.
(2) He customized two of my standard footbeds (new-issue from a pair of shoes — Skecher Shape-Ups — that I’d worn there), adding (a) a 1cm heel lift to decrease the DF I need to stride properly, and (b) a ~0.5cm meditarsal support (which he custom-made out of peel-and-stick fiber stuff) that holds up the balls of my feet under the base of all my toes except my big toes. That will let me load up the front of my foot WITHOUT doing the “claw toe” thing. (In my case, when I do “claw toe”, the big joints on my toe flex, knuckle up, banging on the top of my shoe or ski boot, and the smallest (philange?) joints hyper-extends. So each toe does a sideways “Z” when they’re pushing hard, but the meditarsal support discourages that.

He wants me to wear that customized footbed (and try the stretches) for 6 weeks then see him again to see if anything has changed.

Meanwhile, my right knee has been bothering me — mostly when I walk stairs, esp. down — and the sports-med Doc who’s been examining that has suggested that I consider custom footbeds in case the kneecap (patella) is out of place, so maybe this will help. (It already feels better than it did, but it does come and go; we’ll see.)

I was very surprised how concerned this foot-and-ankle-and-gait expert was about my “good” post-op leg — the one that CAN do a bunch of full-height 1-leg heel raises! — and how OK he was with my “bad” non-op leg — the one that has a clear strength deficit, though one that doesn’t seem to affect my running or jumping or bicycling or volleyball playing. And it made me re-think some of my oft-expressed (here) bias against early dorsiflexion stretching. I’ve been quite content with my reduced DF ROM on my post-op side. But I didn’t realize how reduced it was (because dislocating that foot joint fooled me, but not this Doc), and I certainly didn’t realize that doing what I’m doing is threatening the longer-term viability of that foot! (I’d been wondering if getting older and weaker would make me start limping on my other, post-non-op foot when I didn’t have enough calf strength to stride properly, but he made it sound like I’d lose the use of my other, post-op foot, sooner.

There’s today’s lesson from me, FWIW. Maybe the best audience for the message is Orthopedic Surgeons like my first one, who are tempted to trim ruptured ATs short, because it doesn’t do any harm. . . (Too bad they don’t read AchillesBlog.com!!)

Tags: healing short, ROM, stretching, surgery

Posted in Achilles Tendon Rupture | 42 Comments »

A cure for my addiction to AchillesBlog.com?

Written on November 1, 2010 – 2:18 am | by normofthenorth

So here I am, about 10.5 months after “getting the boot” and signing onto the UWO protocol, a few days after tearing my second AT. As some of you have read elsewhere on this site, I’ve generally been delighted with my pain-free and hassle-free recovery since last December, EXCEPT for the LONG wait to recover my full calf strength. I can “push off” normally at the end of any walking stride (for many months now), but I still can’t do even one full-height 1-leg heel raise.

I can finally do SOME 1-leg heel raises, but I’m still only getting an inch or so off the floor. My main exercise for it is the “2 up, 1 down” that Doug53 and others have recommended on various pages. It’s not a huge strength deficit, but it’s clearly there, as long as my knee/leg is straight. (With bent knee, I can do much better.) I’ve thought of going back to my Sports-Med PT clinic and paying for another isokinetic strength test, but this time with STRAIGHT knee, to objectively measure the deficit. Haven’t done it.

Many of you also know that I have been pretty solidly addicted to this site, since very soon after I was talked out of the operation I thought I wanted, last December. I keep coming back, checking all the new posts and blogs, and chiming in whenever I think I can be helpful (and that’s OFTEN! ).

What’s recently changed isn’t my leg, or even my interest, but my heart! For the past ~5 years, I’ve been having periodic echo cardiograms to monitor the progress of a congenitally deformed heart valve — the same Bicuspid Aortic Valve (they’re supposed to be TRIcuspid!) that Arnold Schwartzenegger, Robin Williams, Barbara Bush, Barbara Wallace, and a bunch of NON-famous people were also born with.

Roughly 2% of our species seems to be born with these BAVs, and they often work great — as mine has — until they start working not so great — as mine also has. For the last year, my Cardiologist has expressed more and more concern about my test results, and suggested that I schedule surgery to replace the valve with a new one, maybe this Fall.

When I came back from the inactivity and lack of fitness that accompanies an ATR, I was so out of breath from bicycling up hills etc., that I thought I might have been “symptomatic” for the BAV, which would support that decision. Then that passed! My fitness returned, and I could bicycle as fast as I wanted to, never missing a yellow light or skipping a hill. YAY!

My Cardiologist was more frustrated than pleased for me(!), and seemed almost angry when he conceded that my last Stress Echo Cardiogram (on a treadmill) was “undoubtedly a very good test”! Reluctantly, a few weeks ago, he agreed that I could postpone the surgery ’til the Spring, then we’d see if another postponement made sense or not.

WELL, my symptoms didn’t ACTUALLY start while I was walking from his office to the car, but that would make a better story — and it’s pretty close to the truth. It looks like I’ll be getting “zipped” open for the valve replacement pretty soon, maybe around the end of this month.

So, dear ATR pals, I’ve started two-timing you, and lurking at www.ValveReplacement.org ! And once again I’m the “newbie” with all the questions and none of the answers! I haven’t registered there yet, but I suspect I’ll be “normofthenorth” again, unless it’s already been taken.

As in ATR treatment, there seem to be some interesting new studies and evidence that hasn’t reached all the surgeons yet, and some of them inspire heated discussions and “agreements to disagree”. E.g., some doctors are VERY aggressive in pushing minimally invasive heart surgery, while most doctors still prefer the more established “big zipper” approach. I’m guessing I’ll go with the traditional cure this time. My surgeon seems to prefer it, and also prefers “porcine” (pig) valves compared to bovine (cow) or human-donor valves.

The new-fangled development that I’m going to TRY to get is a new GLUE that’s being tested out to glue the sternum back together after the surgery (in addition to the usual SS-wire sutures)! They call it Kryptonite, and it seems to make the recovery WAY less painful and quicker. (The heart tissues seem to heal a lot faster than the sawn-apart rib cage.) It costs $500/surgery(!), and it’s approved for skull surgery but it’s still in trials for chest surgery. But I think I’ll try hard to get it anyway, even if it costs me $500 and signing a waiver or two.

So if you got the idea that I’m really anti-surgery. . . I’m not! And if you thought that my wimpy heel raises were the main thing keeping me from rejoining my old volleyball team. . . also not.

I doubt that I’ll be quitting you folks Cold Turkey, but I do expect to phase out of this addiction — and probably right into the next!!

Good Luck and Good Healing — to ALL of us!

P.S. After ONE day of lurking there, I’ve already noticed some fascinating “cultural” differences between this site and www.ValveReplacement.org — e.g., here we all use cryptic IDs and show photos and videos that almost always exclude faces. There, many folks have self-portraits for avatars, FirstNameLastName for IDs, and display the date, valve model, and surgeon’s name in their signatures!

Posted in Achilles Tendon Rupture | 154 Comments »

The case for skipping ATR surgery

Written on October 23, 2010 – 12:48 pm | by normofthenorth

Many people come to AchillesBlog.com because they’ve just torn an AT and are wondering what to do. Their first important decision is whether or not to “go under the knife”, to get the ATR repaired surgically. The alternative — non-surgical care — is often badmouthed by “experts” (who should know better, IMHO). Following is an e-mail I just sent to “Rafael” in response to a post where he asked for information on recovery without surgery. If it helps you make a more informed decision . . . well, that’s the main theme of this web-site!

Here’s what I sent Rafael:

Rafael, you can see on the early pages of my blog — http://achillesblog.com/normofthenorth/ — my own story, which partly addresses your question. In late 2001, I tore my right AT (playing competitive volleyball) and got it repaired surgically, because everybody knew that we athletes need surgery to get a good result. Everything went well, and I did get a good result. Back to competitive volleyball at around 10 months, no noticeable deficit.

Last December (2009) I tore the other one (playing even MORE competitive volleyball — 4-on-4 instead of 6-on-6, at 64 years old!) and went to Toronto’s “fanciest” sports-medicine Ortho Surgeon — the chief surgeon of our pro football team — assuming I needed the operation.

He confirmed my ATR, apparently a complete one, and told me that he’d stopped doing the surgery 4 months earlier, after hearing a presentation at a big AAOS conference from the authors of a new study that seemed to prove that ATR surgery has NO benefit! The study randomized 145 patients, half got surgery, half skipped the surgery but got the identical immobilization and exercise and PT protocol. At the end of 6 months and a year, there was NO difference between the groups in strength, Range of Motion (ROM), or re-rupture rate! (BTW, ROM is a key measure of the healed LENGTH of the AT, which is a key factor in functional abilities like jumping and agility. A longer AT limits performance.)

He got a chance to discuss the study with the authors, at the conference, and they answered a lot of his questions. He told me “I didn’t become a surgeon to do surgery that has no benefit, so I’ve stopped doing Achilles repairs.” He gave me a copy of the protocol from that study, done at U. of W. Ontario (”UWO”) — I’ve posted it at bit.ly/UWOProtocol — and he sold me a $150 boot instead of scheduling me for ~$15,000 surgery!

My personal experience is just one “data point”, and I think it’s important not to over-generalize from any individual’s experience. In my case, everything’s gone much faster and more easily and less painfully than it did last time, except recently, when the return of my calf strength seems slower than it did 8 years ago. (I’m about 10 months “post-non-op” now, and my 1-leg heel raise is still hard, and “wimpy”, not full-height.) That’s me, and there’s a growing group of people at AchillesBlog.com who have followed a similar protocol, and most of them are regaining calf strength faster than I am. (There are also lots of post-op people on AchillesBlog.com who are still waiting for calf strength like me.)

Here’s the scientific evidence:

There have actually been FOUR recent randomized studies (all since 2007!) with a similar approach, all showing very similar results. The non-surgical patients get the same strength, ROM, and (very low) re-rupture rates, and they skip almost all the complications, which were significantly higher in most of the studies — things like wounds that don’t heal, infections, and Deep Vein Thrombosis.

If you go to the Wikipedia article on ATR — quick-link bit.ly/Wiki-ATR — the section “6 Treatment” partly reflects my own edits, and the end-notes 4-7 link to online presentations of those four studies. The UWO study is at end-note 7.

Earlier studies, at least up until 2005, seemed to show the opposite — that surgery really was needed to get a good result! My explanation in that Wiki article — that the old results “were primarily artifacts of a selection bias, directing younger, healthier, and fitter patients to surgery, and the rest to non-surgical immobilization” — is only half the story. The other half seems to be that the new studies all gave both kinds of patients a new-fangled fast rehab protocol, with early weight-bearing (WB), exercise, and PT. The old studies used “conservative casting” for non-op patients, with a very long period of total immobilization. Ironically, that approach seems to have produced the high re-rupture rate that many health professionals still associate with non-operative treatment of ATRs.

For a number of understandable reasons, the vast majority of “experts” in this field have NOT changed their practice, or their advice, or their version of “the truth”, since the new studies started coming in. And most surgeons like to do ATR surgery SOON, so way too many patients are being rushed into surgery, even though it seems to be a waste of time and money, and a needless source of pain and risk of complications! Several of us have discussed the “understandable reasons” at AchillesBlog.com.

There are many other often-repeated stories — many of them compellingly LOGICAL-sounding — that seem to be WRONG, according to the evidence. Including these:

“If you have a big GAP in your torn AT, you should get the surgery for sure.” According to the only (small) study on the subject, the size of the gap in the torn AT has NO effect on the non-surgical results! (The POSITION of the tear — high, middle, or low on the leg — also seems to have no effect.)

“Non-op might work OK for PARTIAL tears, but a COMPLETE tear needs surgery.” All FOUR of the modern studies that showed the benefits of skipping surgery, were done on COMPLETE AT ruptures! It may well be true that a good non-op approach works EVEN BETTER on PARTIAL tears, but there’s no evidence either way, AFAIK.

“You don’t want to rush your rehab, because you don’t want to go through this TWICE!” Both surgical and non-op patients seem to show lower re-rupture rates from relatively fast rehab protocols, and higher re-rupture rates from old-fashioned slow protocols with long immobilization and long NWB on crutches. Being on crutches also has its own risks, including falling on the injured leg and re-rupturing!

“Especially if you skip the surgery, you’ll never go back to that high-risk explosive sport. Get used to the couch!” Again, the strength results are the same with and without surgery in all 4 recent studies. And the risk of re-rupturing a torn-and-healed AT after it’s substantially healed — some say 6 months, some say 10 or 12, some say when you can easily do 1-leg heel raises, etc. — seems to be vanishingly small. The vast majority of us CAN return to high-risk explosive sports, and a lot of (probably most) actually DO. Some of us feel 100% or better, many do feel slightly impaired (with our without surgery), especially at first.

You say your “achilles tendon got injured.” I’m assuming that it got ruptured from being over-stressed, like in a sport. If it actually got lacerated, rather than ruptured (i.e., if a broken sheet of glass fell and sliced the back of your foot), then all this evidence and advice is NOT directly relevant to you. The advice may still be good — or not! We’ve got one or two success stories with non-op treatment of AT lacerations at AchillesBlog.com, but they’re just stories, not scientific evidence. The evidence is all about ruptures. Lacerations may turn out to work the same way, or there may turn out to be a benefit from surgery; we don’t know yet.

So, if you’ve torn your AT, I’d say skip the surgery, get a boot, and follow a modern protocol like the UWO protocol. (If anybody does want the surgery, they should also get a boot and follow a modern protocol like the UWO protocol.) I personally recommend a boot that can hinge, like the Donjoy MC Walker I used, or the new VacoCast that’s advertised (and much beloved) at AchillesBlog.com. But initially, you want to be immobilized — boot set NOT to hinge — at a gently toe-down angle, according to the successful UWO approach. (They used a non-hinging AirCast boot with 2cm of hard-rubber wedges under the heel.)

I hope that makes sense, and helps. Good Luck and Good Healing!!

Norm

[I used bold instead of underline, because I can't get UL to work here. I also used block quotes instead of bullet points. Anybody know how to get bullet points working here?]

Posted in Achilles Tendon Rupture | 197 Comments »

Tricks to using AchillesBlog.com and WordPress

Written on October 9, 2010 – 12:44 am | by normofthenorth

It’s gradually been dawning on me that it would be helpful to have one spot here, where we can share our fave tips and tricks on using this nifty web-site. Like ways to post, edit, navigate, use widgets, etc., etc.

Obviously, Dennis has outlined many of the basic steps, starting on the main page. But I’ve discovered a few tricks of my own, and I bet lots of you use some tricks that I haven’t discovered yet. And lots of this is a challenge to newbies — though I bet some of them could teach me some tricks, too.

So here’s a place for us to share what we’ve learned, that ISN’T about tendons and ankles and boots and casts and crutches. . . (If I’ve missed a good existing collection of tips and tricks, please post the link here.)

I’m no expert, but I’ve picked up some, and here are a few of my own:
1) We bloggers can choose a “theme” for our entire blog, by clicking on Appearance | Themes in the menu at the top of the page. The choice affects a LOT, not just the cosmetic appearance of our pages. Some themes seem to allow commenters to edit their comments for 15 minutes, and others don’t. Some allow the (really helpful) ATR Timeline widget to appear, and others don’t. Some show links to earlier and later Posts in that same Blog — and others don’t. There may be a tradeoff between a theme that really looks nice, and “looks like you”, and one that actually DOES what you want it to do!
2) If you’re reading somebody’s blog post, and the comments, and you want to see earlier (or later) posts, you MAY be able to click on a link below the post, or one of several links in the margin. Or you may see a calendar that shows (and links) each MONTH that contains posts from that blogger. If not, you can see links to a bunch of that person’s posts by editing the URL, so it just shows http://achillesblog.com/USERNAME . Only instead of “USERNAME”, just leave that blogger’s AB.com ID (like “normofthenorth” for me). You should see a bunch of original posts, with links to the comments for each, and a link to earlier posts.
3) Under “Settings“, we have a lot of useful choices. We can make it easier or harder for spammers to post comments. We can make it easier or harder for posters to add URLs to their posts — withOUT their posts going into limbo until you expressly OK them. (If you click on “Comments”, you can see if there are any posts awaiting approval, and either clear them, or delete them.)
4) If you’ve never used the “Search AchillesBlog” gizmo at the top right of the Main Page, it’s often Very Useful. For finding answers and advice on specific issues, for tracking down a post or comment that you’re SURE you read SOMEWHERE, but can’t recall where, etc. (I think it just triggers Google to do a search that starts with file:http://achillesblog.com/ , then adds your search terms.)
5) If you’ve got a blog of your own, but haven’t installed that ATR Timeline widget, I think you should. If you’ve tried and it doesn’t appear, it’s probably because your choice of “theme” doesn’t have a spot for it. Me, I’d change themes, but that’s your choice.
6) The only problem with that wonderful widget — other than saying that we’re all so many weeks and days “Post-OP”, even if we cleverly AVOIDED the “OP”!! — is that it keeps running! By that I mean this: if you go back to read an early blog post from an old-timer like me, you may be reading about my experience at 6 or 12 weeks post-non-op, but the Widget will tell you that I’m 43-odd weeks post-non-op, which is true TODAY, but NOT when that post was posted. If you’re lucky, the text will mention how long it’s been; if not, you’ve got to do some math to figure out how soon that poster was FWB, or doing 2-leg heel raises, or driving, or whatever.
7) At least on my blog, with my theme, I can’t get the Underline function to work. Bold works fine, italic is fine, but

underline

comes out like that. Anybody got a solution?

Enough for now, at least from me!

If you’ve got some faves of your own, or some better ways of doing the above, please join in. I’ve never posted a photo, or a blog linked to a video, so people who’ve succeeded at that, please share. If we do a good enough job, maybe Dennis will link this page to the Main Page, to help newbies get up to speed.

Posted in Achilles Tendon Rupture, Uncategorized, Using this site | 4 Comments »

And the results are IN!

Written on May 6, 2010 – 7:28 pm | by normofthenorth

As I posted last night,

Tomorrow my PT puts me on the computerized machine that’s going to compare my healing ankle-and-AT’s performance to the other side. My ROM is pretty close to 100%, but I expect the various strength benchmarks to be maybe in the 45%-65% range. We’ll see.

Well, I’ve now got a spiffy 1-page summary printout with full-color graphs and a chart with a bunch of numbers showing my quantitative results at 21 weeks, just under 5 months “post-NON-op”.

I thought there would be more different measurements, including inversion and eversion. All they measured was strength and ROM in plantar- and dorsi-flexion. Not static strength, but dynamic strength, at just one rate of flexion — 60 degrees per second.

As I already knew, my ROM is virtually identical on both sides — in fact, a hair better on the “involved” (aka “bad” or “healing” or “left”) side, at 60.3 vs. 58.4 degrees!

My dorsiflexion torque and power and work are ALSO a bit better on the “involved” (aka “bad” or “healing”) side, by margins ranging from 0.8% (peak torque) to 5.8% (total work), with “max rep total work” and “avg. power” falling in-between.

I am “left-footed”, so maybe that’s why that foot is stronger at dorsiflexing? That’s also a move that I work hard all Summer, while “hiking” out the side of a small sailboat — and the first race is tomorrow night!!

On the colored bar charts, they included 3 bars: my “involved” foot, my “uninvolved” foot, and a bar marked “goal”. The PT/operator said that was NCAA athletes. Interestingly, while my “good” foot is 12.7% below the “goal” in PLANTARflexion (in “PK TORQ / BODY WEIGHT %”), I’m more than 7% BEYOND the “goal” in DORSIflexion! (Maybe they weren’t collegiate dinghy racers!)

In the “real bottom line” of plantarflexion strength — a pretty pure test of the strength of my healing/healed AT and my atrophied-and-recovering calf muscle — the “deficit” ranges from 29% (peak torque) up to 37% (”avg. power”), with “max rep total work” and “total work” falling in-between at 32.1% and 32.8% deficits.

So my recovering ankle-AT-calf is 63%-71% as strong/powerful as my “good” one, depending on the measurement. That’s a bit higher than I was guessing, which I think is good, right? The PT who did the measurement, and my Ortho surgeon — remember I did NOT have surgery on my AT this time! — both thought I was doing well considering the time.

Actually, I experienced a bit of a strength breakthrough this morning, before I went for the test — I SORT OF did my first 1-leg heel raise, SORT OF. At this point, I can support my entire weight (which is about 5-10 pounds higher than it SHOULD be!) on the ball of my foot, AS LONG AS MY KNEE IS BENT. Specifically, I can “roll” forward on that foot, with all my weight on it, until my heel is up in the air, with my knee bent, and hold it.

It’s definitely not a normal, full-strength, stand-tall heel raise, but it’s one more little landmark on this “marathon” we’re on, and it does indicate that this long (and sometimes frustrating) “plateau” does actually have a slope, and it is going in the right direction. It’s nothing like the rapid-fire early progress of “losing” heel lifts, getting to PWB & FWB, and getting into 2 shoes, but it’s there, and it’s cheery!

On a functional note, I’ve really been enjoying bicycling and even short bursts of running, and my bod is in much better shape than it was just recently — e.g., when I was skiing in Whistler on April 11-17!

Onward and upward. Good healing, all!

Posted in Achilles Tendon Rupture | 97 Comments »